Provider Demographics
NPI:1598357683
Name:MD PHYSICAL THERAPY CENTER FOR LONGEVITY
Entity Type:Organization
Organization Name:MD PHYSICAL THERAPY CENTER FOR LONGEVITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AO/PT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARION
Authorized Official - Middle Name:MARKETTIA
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:142-371-8162
Mailing Address - Street 1:4945 BAL HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37416-1714
Mailing Address - Country:US
Mailing Address - Phone:423-718-1627
Mailing Address - Fax:423-855-1482
Practice Address - Street 1:4945 BAL HARBOR DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37416-1714
Practice Address - Country:US
Practice Address - Phone:423-718-1627
Practice Address - Fax:423-855-1482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1225430713OtherPRIVATE INSURANCE COMPANIES